We, the following members of the Board of Medical Experts after careful personal examination, hereby certify that Shri/ Smt. / Km ........................... aged about ................... ....…………. s / o, w /o, d / o, Shri .............................. resident of ............................... is dead on ac- count of permanent and irreversible cessation of all functions of the brain-stem. The tests carried out by us and the findings therein are recorded in the brain-stem death certificate annexed hereto.

4. Name and address of next of kin or person .............................

responsible for the patient (if none exists, this ..................................................... must be specified) ..................................

5. Has the patient or next of kin agreed to any transplant? ............................

6. Is this a Police Case? Yes................ No..............

(B) Pre-Conditions:

1. Diagnosis: Did the patient suffer from any illness or accident that led to irreversible brain damage? Specify details: ......................... ..........................................................................................

Date and time of accident/onset of illness .................................

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